Provider Demographics
NPI:1821442666
Name:POWELL, KELLY (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E MAIN ST STE 106
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5853
Mailing Address - Country:US
Mailing Address - Phone:747-500-4253
Mailing Address - Fax:747-356-4377
Practice Address - Street 1:900 E MAIN ST STE 106
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5853
Practice Address - Country:US
Practice Address - Phone:747-500-4253
Practice Address - Fax:747-356-4377
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-18
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18870208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice